Leadership & Management Ethical - Legal

A nurse discontinues patient-controlled analgesia per the health care provider's prescription, and
notes that there is 10 mL of morphine sulfate left in the cartridge. All other nurses on the unit
appear busy. What is the most appropriate action by the nurse?
Opioids (eg, morphine, hydromorphone, fentanyl) are controlled medications, regulated in the

United States by the Controlled Substances Act and in Canada by the Controlled Drugs and
Substances Act. These laws contain regulations (eg, methods of disposal) for various controlled
substances.
To properly dispose of leftover opioid medication in a patient-controlled analgesia pump, the
nurse must have a second licensed nurse witness the waste of the medication (Option 3).
Hospital policy should be followed to properly waste the medication and discard the empty
cartridge. When a controlled substance is discontinued, the nurse documents the date, time,
amount used, reason for the waste, and amount wasted.
(Option 1) Unlicensed assistive personnel (UAP) cannot witness the waste of medication as it is
outside their scope of practice. Two licensed nurses must document this process.
(Option 2) Simply documenting that another nurse is not available does not follow government
regulations for wasting controlled substances. Disposal should occur only when a second
licensed nurse is available as a witness.
(Option 4) It is never appropriate to waste a controlled substance without the witness of another
nurse. In addition, nurses should never document or sign off on anything that was not personally
witnessed or completed as this constitutes falsified documentation.
Educational objective:
Waste of controlled substances (eg, opioids) must be witnessed by two licensed nurses to comply
with facility policy and government regulations.
The nurse is caring for a 4-year-old child in the emergency department who has a 104 F (40 C)
temperature, is obtunded, and has a positive Kernig's sign. The parents are refusing antibiotics
and any treatment. The parents state that their religious belief is to trust in just prayer and
believe the child will receive divine healing. What action does the nurse anticipate?
A competent adult has the right to make any decision regarding the client's health care even if the
provider does not believe it is in the client's best interest. However, parents do not have the right
to place their minor child in a life-threatening position. Parents have legal authority to make
choices about their child's health care, but not when they do not permit life-saving treatment or
when there is a potential conflict of interest, such as child abuse or neglect.
The hospital will seek court-appointed custody to treat this child who is seriously ill with
dangerously high temperature and signs of severe neurologic deficit. Bacterial meningitis
presents with high fever, change in level of consciousness, nuchal rigidity, and meningeal
signs (positive Kernig's and Brudzinski's signs). Antibiotic treatment is essential.
(Option 1) The parents will not be allowed to take this child out of the hospital against medical
advice as it will endanger the child's life. It does not matter that it is a religious reason for the
desired AMA.
(Option 2) Durable power of attorney for health care (health care proxy) is something a
competent adult establishes when that adult can no longer self-advocate. Parents are
automatically the legal guardians and decision makers for their minor children as long as the
decisions do not put any of their children in danger.
(Option 4) The ethical principle of autonomy is deciding for oneself. In this case, the child's
best interest is priority and the legal authority takes precedent.
Hospital administration will obtain legal protective custody of a minor child if the parents are
deciding against life-saving measures for their child or when there is child abuse/neglect.
A male client has terminal metastatic disease. He arrives at the emergency department with
respirations of 6/min and an advance directive indicating to withhold resuscitative efforts. What
should the nurse's response be?
Advance directives are prepared by a client prior to the need to indicate the client's wishes. A
living will gives instructions about future medical care and treatment if the client is unable to
communicate. A medical power of attorney is the individual designated to make health care
decisions should a client become unable to make an informed decision. It allows more flexibility
to deal with unique situations.
Because the client has indicated specific desires, these should be honored. This is especially true
as the client has a terminal condition (versus, for example, an acute choking episode that could
be easily reversed). Oxygen can provide comfort and is not resuscitative when given by nasal
cannula.
(Option 2) Advance directives are determined ahead of time to guide decision making at the
time of the event. The client can indicate a desire to make a change, and the original decision
should be honored. This client could be experiencing hypoxia and thus not thinking as clearly as
when the advance directives were made. Asking about changes could imply that he should make
a change, which is not true. The original decision should be honored; however, the client can
indicate a desire to make a change.
(Option 3) The client's advance directives take legal precedence over the spouse's wishes. The
spouse is consulted when there are no advance directives or durable power of attorney for health
care.
(Option 4) Advance directives include living wills with written directives on how to handle
situations. A medical power of attorney is used in situations not covered by the written
directives. This client has indicated his wishes. A durable power of attorney for health care is
used only when clients have not expressed wishes or cannot speak for themselves.
Advance directives include a living will (specific situations put in writing) or a medical power of
attorney (an individual appointed when the clients are unable to speak for themselves). The
client's wishes should be honored.
A visiting family member of a hospitalized client reports sudden onset of a headache and
numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What
is the most appropriate response by the nurse?
Providing care establishes a legal caregiver obligation/relationship between the nurse and the

visitor. If a relationship is started, the nurse has a duty to continue care until the visitor is stable
or other health care personnel can take over. If proper care is not continued, the nurse could be
accused of negligence (ie, failure to act in a prudent manner as would a nurse with similar
education/experience).
This visitor's symptoms are potentially serious as sudden onset of headache and numbness in half
of the body may indicate stroke. In the event of a visitor emergency, the nurse should not
establish a caregiver relationship but rather implement facility protocol to help the visitor get to
the emergency department promptly to receive immediate assessment and further
evaluation (Option 2).
(Options 1 and 4) Asking the visitor to call the health care provider (HCP) or giving advice to
lie down delays the essential assessment and treatment that this visitor with potentially serious
symptoms requires.
(Option 3) When a nurse provides care (eg, takes blood pressure), a client-caregiver relationship
is established. The nurse caring for a visitor is ill-equipped to provide care without any HCP
prescriptions in place and risks being negligent.
Providing care establishes a legal caregiver obligation/relationship between the nurse and a
visitor. In the event of a visitor emergency, the nurse should refrain from actions that establish
this relationship and instead implement facility protocol to help get the visitor promptly to the
emergency department.
A 16-year-old walks in unaccompanied by a parent and approaches the clinic nurse. The
adolescent asks to be tested for a sexually transmitted infection (STI). How should the clinic
nurse respond?
"Mature minors" are adolescents who are age 14-18 and are deemed able to understand
treatment risks. They are legally allowed to give independent consent to receive/refuse treatment
for some limited conditions. Classically, these conditions include testing and treatment
for STIs, family planning, drug and alcohol abuse, blood donation, and mental health care.
A minor who is a parent, pregnant, or an emancipated minor can also give consent. An
emancipated minor is a self-supporting adolescent under age 18 who is married, on active duty in
the military, granted emancipation by the court, or not living at home.
(Option 1) This information could be requested if a professional relationship with assessment is
established. It would be beneficial to reinforce the concept of safer sex regardless. However,
that is not the essential need as STIs can be transmitted even when protection is used.
(Option 2) Minor children ordinarily need parental consent unless specific conditions are met.
In this case, the nature of the request allows the care to be given.
(Option 3) STIs do not always have obvious signs/symptoms that would allow the client's needs
to be determined accurately.
Mature minors are adolescents between age 14-18 who can give independent consent for limited
conditions such as STIs, family planning, drug and alcohol abuse, blood donation, and/or mental
health care.
Which statements related to ethical nursing practices are correct? Select all that apply.
Ethical principles guide decision making and appropriate behavior. Justice is treating every
client equally regardless of gender, sexual orientation, religion, ethnicity, disease, or social
standing (Option 4). Accountability refers to accepting responsibility for one's actions and
admitting errors (Option 1).
Nonmaleficence means doing no harm. It also relates to protecting clients who are unable to
protect themselves due to their physical or mental condition. Examples include infants/children,
clients under the effects of anesthesia, and clients with dementia (Option 5).
(Option 2) Autonomy is freedom for a competent client to make decisions for oneself, even if
the nurse or family does not agree (eg, informed consent, advanced directive). The nurse can
provide information and should respect the client's decisions.
(Option 3) Confidentiality means that information shared with the nurse is kept in confidence
unless permission is given to share or it is required by law to be shared to protect the client
and/or community (eg, reportable infectious diseases). If a client discusses suicidal ideation with
the nurse, it must be appropriately reported to protect the client from self-harm.
Accountability is accepting responsibility for one's actions. Autonomy is making an informed
decision about treatment for oneself. Confidentiality is not sharing information unless
permission is given or required by law. Justice is treating every client equally. Nonmaleficence
is doing no harm.
The charge nurse supervising a graduate nurse would need to intervene when the nurse violates
health information privacy laws with which action? Select all that apply.
Nurses need to maintain privacy and confidentiality when caring for clients. Health care workers
(HCWs) need to use the minimum necessary standard (reasonable precautions) to protect a
client's health information.
Confidentiality is violated when information about a client's personal health (eg, diagnosis, test
results) is accessed by or given to those without permission or without a "need to know." For
example, a transport technician may require pertinent client information (eg, fragility) to
transport a client safely but never needs to know the client's exact diagnosis (Option 2). Other
violations include when HCWs access medical records of clients not currently assigned or
discuss client diagnoses with nonessential personnel (Options 1 and 4).
Certain incidental disclosures are allowed if reasonable precautions are taken. Common
precautions include:
 Allowing medical record access to a HCW only when necessary to perform job duties
 Employing room dividers/curtains in semiprivate spaces (Option 3)
 Avoiding discussions about clients and their conditions in public areas
 Listing only last names on whiteboards at nurses' stations (Option 5)
 Placing communication whiteboards where they are least visible to the public
 Communicating with lowered voices in semiprivate spaces (eg, nurses' stations, client
rooms)
Only health care personnel requiring client health information to carry out their job duties should
have access to or be advised of this information. Nurses, health care providers, and hospitals
should take reasonable precautions at all times to safeguard client information.
During change-of-shift report, the nurse going off duty notes that the nurse coming on has an
alcohol smell on the breath and slurred speech. What actions are most important for the nurse to
take? Select all that apply.
An impaired nurse cannot safely give care regardless of the reason for impairment. If
impairment is suspected, the nurse has a duty to take action that will both protect the client and
ensure that the impaired individual receives assistance. The charge nurse/nurse supervisor
should be notified (so the nurse can be replaced and sent home safely), the incident
documented, and the nurse not allowed to give care while impaired (Options 1, 2, and 3).
(Option 4) The off-going nurse will not stay on the new shift to watch for impairment. The
impaired nurse may not behave in an obvious manner while the off-going nurse is watching.
Regardless of these factors, the nurse has alcohol on the breath and slurred speech; by definition
there is evidence of impairment.
(Option 5) Confronting the impaired nurse in a hostile manner does nothing to protect the client
and offers no support to the nurse. Confrontation may be necessary if the client is in immediate
danger (eg, the impaired nurse draws up a medication for administration). The off-going nurse
should notify the charge nurse so that facility authorities can collaborate with the governing state
board of nursing to carry out appropriate investigation, discipline, and supportive interventions.
Most state nurse practice acts allow rehabilitation for a cooperative professional rather than
automatic loss of license.
A nurse who is impaired by alcohol cannot be given client responsibility. The recognizing nurse
should notify the supervisor, document the incident, and not give client responsibility to the
impaired nurse.
A client with end-stage renal disease, oxygen-dependent chronic obstructive pulmonary disease
(COPD), and a Do Not Resuscitate (DNR) code status is admitted to the medical floor for COPD
exacerbation. The nurse walks into the room and finds that the client is not breathing. What
should the nurse do first?
The nurse has a medical order stating that the client should not be resuscitated. Therefore, the
appropriate first action is to assess the apical pulse. Then the nurse should call the HCP. If the
client's family members are present, the nurse should explain what is happening and make sure
that they have support.
(Option 1) Activating the code system is not appropriate as this client has an order to withhold
resuscitation.
(Option 2) The nurse should assess the client and then call the HCP. A stat page is not needed
when the client is DNR.
(Option 4) Measuring the blood pressure is not appropriate if this client has stopped breathing.
Checking an apical or central pulse would be appropriate after noticing that the client is not
breathing.
A DNR order requires the nurse to withhold resuscitation in the event of a cardiac or respiratory
arrest. If an event occurs, the nurse should assess for breathing and check the central or apical
pulse. After performing these actions, the nurse should call the HCP to confirm the death.
The nurse witnessed a signed informed consent for an inguinal hernia repair surgery. During the
procedure, the surgeon discovers a secondary ventral hernia that also requires repair. Which
action should the nurse perform?
Informed consent is required before any nonemergency procedure. The 3 principles of informed
consent include:
 The surgeon explains the diagnosis, planned procedure with risks and benefits, expected
outcome, alternate treatments, and prognosis without surgery.
 The client indicates understanding of the information.
 The client is competent and gives voluntary consent.
The nurse is responsible for witnessing the client's signature and ensuring that the client is
competent and understands information provided by the surgeon. Clients unconscious or under
the influence of mind-altering drugs (eg, opioids) cannot provide consent. If the sedated client
requires procedures not listed on the consent form, the client's medical power of attorney, legal
guardian, or next of kin should be contacted so that the surgeon can explain the situation and
obtain consent (Option 2).
(Option 1) Modifying a consent form after it has been signed is an illegal falsification of
documentation.
(Option 3) Unless family members deny consent or cannot be reached, it is in the client's best
interest to have the hernia repaired now rather than go through the physical and financial strain
of a second surgery.
(Option 4) Procedures can be performed without prior consent only when lifesaving measures
are necessary. Obtaining consent after a procedure is illegal and considered assault and battery.
Informed consent is required before any nonemergency procedure. If the need for an additional
procedure is discovered during surgery, the client's medical power of attorney, legal guardian, or
next of kin should be contacted to provide consent.
The nurse finds a client on the floor in the client's room. Based on the documentation shown in
the exhibit, the nurse made an incorrect entry in the client's medical record at what time? Click
on the exhibit button for additional information.
All incidents, accidents, or occurrences that cause actual or potential harm to a client, employee,
or visitor must be reported. The person who witnesses an unusual occurrence or event must file
an incident report in the institution's computer documentation system using an electronic form.
Alternately, a paper form may be completed and filed. The purposes of the report are to inform
risk management of the occurrence, allowing them to consider changes that might prevent
similar incidents, and to notify administration of a potential litigation claim.
The nurse should not document that an incident report was filed, or refer to the incident
report in the medical record.
(Options 1, 2, and 4) Because the incident report is not a part of the medical record, an
objective note should be placed in the client's medical record documenting the facts and events
of the incident, HCP notification and findings, prescriptions, treatment, follow-up care, and
monitoring.
The person who witnesses an unusual occurrence or event must file an incident report in the
institution's computer documentation system, using an electronic form. The nurse should not
document that an incident report was filed or refer to the incident report in the medical record.
The parent of a child treated for injuries consistent with suspected child abuse has been told that
a report will be made to Child Protective Services (CPS). The parent says angrily to the nurse, "I
don't know why this is being reported. I told the health care provider (HCP) that it was an
accident." What is the best response by the nurse?
In discussing the reporting aspect of suspected child abuse with a caregiver, the nurse needs to
convey an attitude that is not judgmental, punitive, or threatening. Whether or not the parent has
actually harmed or abused the child, the parent needs to know that a report will be made, why it
is being filed, and an investigation will be conducted by a CPS worker and/or by the police. The
nurse should emphasize that the primary concerns are for the safety and well-being of the child
and that reporting is mandatory for the types of injuries sustained by the child.
It is not unusual for a parent to react to this information with denial and/or anger. The nurse
needs to anticipate that such a reaction may occur and maintain a supportive, empathetic, and
nonaccusatory approach.
(Option 1) This response also diverts the need for the nurse to provide a response or explanation
to the parent. The child's caregiver should be told why the report is being filed.
(Option 2) This response is nontherapeutic. It diverts the need for the nurse to respond to the
parent's question, and it does not provide information or education.
(Option 4) This response is confrontational and could give the parent the impression that the
nurse and health care team do not believe the story of how the child sustained the injuries. The
parent could react with a heightened sense of anger.
When discussing suspected child abuse with a caregiver, the nurse needs to be supportive and
empathetic and maintain a neutral, nonpunitive and nonaccusatory manner. The parent needs to
be told that the safety and well-being of the child are the primary concerns and that certain types
of injuries and/or situations must be reported to the appropriate CPS agencies.
Which of the following are examples of medical battery? Select all that apply.
Battery is the intentional touching of a person that is legally defined as unacceptable or

occurs without the person's consent. Many routine actions that are permissible when proper
consent is obtained would otherwise be considered medical battery. Furthermore, actions can be
considered battery even if no physical injury results. Any health care provider (HCP) who
performs a medical or surgical procedure without receiving the required informed consent from a
competent client (or parent/legal guardian in the case of a child) is committing battery and could
be legally charged (Option 3).
A competent client has the right to refuse any treatment, even if it is for the client's benefit. The
nurse should help the client understand the need (eg, informed refusal), but the client's decision
should be upheld. Proceeding to administer treatment to a competent client who has refused that
treatment is medical battery (Option 4).
(Option 1) The temporary restraint for this minor child is needed for a therapeutic intervention,
and it is implied that the parent consents to its use.
(Option 2) Using a restraint to prevent a client from inadvertently removing essential medical
interventions is an acceptable medical precaution. A prescription from the HCP is required, and
the nurse is responsible for performing appropriate, timely assessments related to the restraint.
This is not an example of battery as there is a medical reason for the restraint and a
prescription/order was obtained.
(Option 5) This is an example of assault. Assault is a deliberate threat with the power to carry
out the threat.
Battery is touching that is legally defined as unacceptable or occurs without consent. Examples
include performing a procedure despite a competent client's refusal or without obtaining proper
consent from a competent client (or parent/legal guardian when the client is a child). Assault is
the threat of battery.
During shift change, the night nurse notices that the graduate nurse administered IV dopamine
instead of the prescribed norepinephrine for a client with sepsis. What should the night nurse
do first?
When a medication error occurs, client safety is the nurse's first priority. The nurse should
assess the client immediately for any adverse effects and inform the healthcare provider
(HCP) (Option 3). Before taking any other actions, the nurse must ensure that the client is
stable.
Following client stabilization, the error should be reported to the appropriate nursing authority
(eg, supervisor, manager), and an incident or occurrence report should be filed within 24 hours.
(Option 1) Prior to administering the correct medication, the HCP should be informed to ensure
that the original medication is appropriate in light of the medication error. Additional
medications or therapies may be necessary to reverse the effects of the medication given in error.
(Option 2) Although it is important that the graduate nurse has a chance to learn from the
mistake, ensuring client safety is the first priority. An incident report can be filed after the client
is stable.
(Option 4) Discontinuing dopamine without providing another medication for hemodynamic
stabilization may harm the client. The nursing supervisor should be informed after client
stabilization.
Client safety is the first priority when a medication error occurs. The nurse should assess the
client and inform the HCP about the error before reporting to nursing management and
completing an incident report.
A nurse cares for a client on life support who has been declared brain dead. Which intervention
is appropriate at this time?
Local organ procurement services (OPS) are notified for every client death, per hospital
protocol (Option 2). If the client is deemed appropriate as a donor, then OPS collaborate with
hospital staff in approaching the client's family about organ donation.
Cardiac support (eg, dopamine, epinephrine) and respiratory support (eg, ventilator) continue
as organ donation is discussed and/or performed. Life support is withdrawn only if the client is
not a candidate for donation due to physiological reasons or the client/family does not consent.
(Option 1) Organ donation is discussed before final arrangements and funeral plans are made.
In most cases, the family is referred to the hospital chaplain or someone outside the hospital for
assistance with final arrangements.
(Option 3) Medical and nursing care would continue as organ donation is discussed due to
organ and tissue perfusion being necessary for viable donation.
(Option 4) Local OPS are contacted before life support is removed so that physiological support
is continued in the event that the client is a viable donor.
All client deaths are reported to local organ procurement services, per hospital protocol. Life
support is continued until a decision for organ donation is reached so that organs and tissues
continue to receive perfusion and oxygenation.
A client was treated in the emergency department 2 days ago. The nurse makes a follow-up call
to say that a culture shows that the client needs an antibiotic. The client's spouse answers the
phone, says that the client is at work and doing fine, and that the client does not need the
antibiotic. Which is a priority action for the nurse?
The spouse does not have the authority to refuse the required medication for the client as the
client is competent and has decision-making capacity. An informed refusal includes knowing the
risks and benefits of the decision, including the potential of latent infection/damage in this case.
If the client does not call back, the typical facility policy is to try to reach the client by phone 3
times, then by certified letter, and (depending on the seriousness of the result) then sending
the police to contact the client.
(Option 1) The prescription can be called into the pharmacy, but there is no guarantee that the
client will pick it up and take it in light of the spouse's response. Speaking to the client is the
priority.
(Option 2) The statement and attempts for contact should be documented, but the first priority is
client care.
(Option 3) The emergency department physician should be notified of the conversation, but the
priority is to speak to the client and explain the importance of the new follow-up treatment. If
the client has a primary care provider, the nurse could also communicate with that office to aid
follow-up.
A competent adult with decision-making capacity can refuse essential treatment; the client's
spouse does not have that legal authority. Treatment refusal must include awareness of the risks
and benefits.
The clinic nurse is teaching a client about the advance directive form that needs to be completed.
Which statement indicates that the client understands the information?
When the advance directive is completed, a copy should be placed in the client's medical record
and copies should be given to everyone listed as health care proxies. The client should also keep
a copy in a safe place.
(Option 1) The advance directive form does not need to be notarized, and so it can be
completed in the health care setting if there are 2 witnesses.
(Option 3) The advance directive is used to document a client's wishes, but it is not a medical
order. It will not prevent from performing CPR on a client when necessary. If this client does
not want CPR, a portable "do not resuscitate" (DNR) order should be used to ensure that the
DNR order is followed outside the hospital setting. Types of portable orders include a POLST
(Portable Orders for Life Sustaining Treatment) form, an out-of-hospital DNR, and a DNR
bracelet.
(Option 4) Two witnesses are required for completion of the advance directive form. The
witnesses cannot be health care providers involved in the care of the client or individuals named
as health care proxies in the document.
An advance directive is placed in the client's medical record and copies are given to health care
proxies. Two witnesses are required for completion of the advance directive, but they should not
be the health care proxies listed in the document.
The medical-surgical nurse cares for a group of clients. Which client situations would prompt
the nurse to notify the health care provider during the middle of the night? Select all that apply.
The nurse contacts the health care provider (HCP) for certain circumstances, regardless of the
time of day. An emergent call is warranted if a client:
 Falls
 Deteriorates significantly or dies
 Has critical laboratory results
 Needs a prescription that requires clarification
 Leaves against medical advice or runs away
 Refuses key treatments in a relevant period
The HCP should be called after the initiation of hospital protocols (eg, stroke, code blue) and
after a concerning assessment finding (eg, significant change in vital signs, unilateral drift,
change in level of consciousness, signs of trauma after a fall ) (Options 1 and 2).
Administration of heparin is normally discontinued prior to surgery due to the increased risk of
bleeding and should be clarified with the HCP (Option 3).
A serum sodium of 124 mEq/L (124 mmol/L) (normal: 135-145 [135-145]) represents a critical
value that can lead to altered mental status and seizures (Option 4).
(Option 5) Clients have the right to refuse treatment; there is no indication that the client needs
pain medication. With additional explanation, the client might reconsider if and when symptoms
occur.
The nurse should notify the health care provider, regardless of the time, for acute client
deterioration (eg, neurological changes), critical laboratory values, falls, or death. Other reasons
include prescription clarification and the client leaving against medical advice or refusing a key
treatment.
Which pediatric presentation in the emergency department should the nurse follow up for
possible abuse and mandatory reporting?
Infants do not start rolling until age 4 months and normally roll front to back at 5 months. This
explanation for the injury does not fit the growth capacity of the child. Because lethargy is
present, head injury must be ruled out.
(Option 2) Congenital dermal melanocytosis (Mongolian spots) are an expected finding.
These are seen on the lower back and/or buttock more often in African American, Asian,
Hispanic, and Native American infants. Although they can be mistaken for bruising and the size
and location should be documented, they are not a concerning finding and usually disappear by
school age.
(Option 3) A toddler's forehead is the height of many tables. Due to toddlers' lack of
coordination, this explanation is plausible in the absence of other concerning findings (eg, child
is afraid of caregiver, multiple bruises of various ages over other parts of the body,
malnourished).
(Option 4) Due to the child's short height, this is a credible explanation. A child can pull water
down from a higher-level stove top. Burns that are suspicious for abuse include scalds without
splash marks; scalds with a clear line of demarcation/immersion ("dunking"); scalds involving
the perineum, genitalia, and buttocks; burns on the back (versus the front) of the child; mirror-
image burn injury of the extremities; and cigarette burns.
Infants begin to roll at age 4–5 months. History that does not match growth and development is
a concern for abuse. Burns with splash, bruises from areas typically hit when falling, and
Mongolian spots are expected findings.
Congenital dermal melanocytosis

The nurse is participating in staff training about protecting clients' privacy and confidentiality.
Which of the following incidents does the nurse recognize as a violation of client
confidentiality? Select all that apply.
The nurse is ethically and legally obligated to protect clients' privacy and

maintain confidentiality of their medical information. Clients' health information should be
shared only with other health care team members directly involved in those clients' care. Report
sheets used by nursing staff often include clients' private health information and must
be shredded at the end of the shift (Option 2). Without the client's permission, information
about the diagnosis or diagnostic tests cannot be shared with a hospital roommate (Option 3).
(Option 1) Health care staff are not required to censor visitor conversation in waiting rooms.
(Option 4) Nurses are obligated to help protect visitors and others by instructing visitors to wear
appropriate personal protective equipment. However, the nurse should not violate the client's
privacy by sharing the client's diagnosis.
(Option 5) Although discussion about specific client information is not permissible, general
discussion about health care topics (eg, a potential cure for AIDS) is not a violation of clients'
privacy.
The nurse must protect clients' privacy and maintain the confidentiality of their medical
information. Clients' health information should be discussed only with health care team
members directly involved in those clients' care. Nurses must also ensure that documents
containing clients' information are shredded after use.
The client has metastatic cancer, and a living will on record indicates that the client does not
want cardiopulmonary or pharmacologic resuscitation. The client is brought to the emergency
department with respirations of 4/min and a heart rate of 20/min. How should the nurse handle
the situation at this time?
The 2 most common forms of advance directives are living wills and durable power of

attorney for health care (health care surrogate/proxy). These take effect when the client cannot
self-advocate. A living will represents the client's wishes regarding actions to be taken in
specific situations. A durable power of attorney is an individual who decides actions to fluid
situations according to an understanding of the client's wishes.
The client was lucid when indicating wishes. Ordinary care is usually considered fluids,
oxygenation, analgesics, and antibiotics. The client has a terminal illness, and aggressive
interventions would probably be futile over the long term. The client's wishes should be
honored.
(Option 1) Artificially ventilating a client is part of cardiopulmonary resuscitation. The client
has indicated not to be resuscitated. However, nasal cannula oxygen can be given for comfort.
(Option 2) If the client indicates a change of mind, it should be honored. However, a client
with respirations of only 4/min and a heart rate of 20/min probably does not have adequate
perfusion and oxygenation to the brain to make the best decisions (if alert and oriented). The
client's wishes were indicated when the client was able to think clearly, and these wishes should
be honored at this time.
(Option 3) A durable power of attorney takes effect when there is no living will indicating what
actions to take on the client's behalf.
Two common advance directives are a living will (dealing with specific events/issues) and a
durable power of attorney for health care (eg, an individual who can make decisions on the
circumstances in light of the client's wishes). A client's specific wishes as indicated should be
honored.
Which emergency department clients cannot be allowed to sign out against medical
advice? Select all that apply.
To leave against medical advice (AMA), the client must be legally competent to make an

educated decision to stop treatment. Disqualifications for legal competency include altered
consciousness, mental illness (ie, a danger to self or others), and being under chemical
influence (eg, drugs or alcohol).
The client who drank a 1 L bottle of vodka is intoxicated (Option 2). The client who hears
voices has psychotic symptoms and is potentially homicidal (Option 3). The manic client who
has not eaten in 5 days is a potential danger to self and cannot leave AMA (Option 4).
For a competent client to leave AMA, the health care provider must explain the risks of
discontinuing treatment. The nurse must witness and document the discussion on risks of
leaving AMA and the client's understanding of these risks ("informed refusal"). A client leaving
AMA can, and should, receive discharge instructions and the option to return at any time.
(Options 1 and 5) Clients have the right to leave AMA, even if it is not in their best interests to
leave (eg, even if potentially life-threatening). Not allowing a competent client to leave AMA is
a form of false imprisonment, a legally liable action by the nurse.
The client must be legally competent to leave against medical advice. Disqualifications for legal
competency include impairment by drugs or alcohol, altered consciousness, and mental illness
(ie, a danger to self or others).
While reviewing prenatal records with a client and her partner, the nurse notes documentation in
the medical record indicating that the client is a G2P0. However, the client denies a previous
pregnancy. Which action by the nurse is appropriate?
When reviewing obstetric history, the GTPAL notation system gives the health care provider
information about a client's past pregnancies. This notation may be shortened to gravida (ie,
number of previous pregnancies) and para (ie, number of births after 20 weeks). For example, a
G2P0 indicates 1 prior pregnancy ending before 20 weeks and 1 current pregnancy.
The nurse should be cautious of discussing obstetric history with a client in front of the partner
or family and not assume that others have knowledge of the client's past pregnancies. If there is
a discrepancy between what the client discloses in the interview and the medical record, the
information should be clarified when the client is alone to maintain confidentiality (Option 3).
(Option 1) The nurse should not change information in the medical record until the information
is clarified appropriately with the client.
(Option 2) Although the client's medical record indicates a previous pregnancy, it is not
appropriate to ask if the pregnancy was an abortion or a miscarriage in front of the client's
partner.
(Option 4) Explaining the need for accurate information is not appropriate at this time and does
not assist with clarifying the client's obstetric history in a private manner.
The nurse should be cautious of discussing a client's obstetric history in front of the client's
partner or family to avoid breaching confidentiality. Clarification or further questioning about
the client's history should take place when the client is alone.
GTPAL system for obstetric history notation
The number of times a woman has been pregnant, regardless of pregnancy

G Gravida
outcome
T Term The number of pregnancies delivered at 37 w 0 d gestation & beyond
The number of pregnancies delivered from 20 w 0 d gestation through 36 w

P Preterm
6 d gestation
The number of pregnancies ending before 20 w 0 d gestation; these may be

A Abortion
spontaneous (miscarriage) or induced abortions
L Living The number of currently living children
An unaccompanied 16-year-old girl comes to the emergency department with severe abdominal
pain and vomiting. The client has a temperature of 102.2 F (39 C) and a pulse of 120/min and is
lethargic. The client's parents are out of town, and no guardians can be reached. How should
this client's care be handled?
Exceptions to informed consent by parent/guardian in minors
Emergency care  Condition in which delay of treatment is life threatening
 Parent
 Married
Emancipated minor  Military service

(adolescents)  Financially independent
 High school graduate
 Homeless
 Sexually transmitted infection
Specific medical care  Substance abuse (most states)

(adolescents)  Pregnancy care (most states)
 Contraception
An unaccompanied minor should be treated if the medical condition is an emergency and

should be assessed and stabilized. This client clearly has a medical need and could suffer
consequences if not treated. In this scenario, care should be rendered and then explained later to
the parent or guardian. This approach is supported by the ethical principles of beneficence and
nonmaleficence.
In addition, underage clients may consent in certain circumstances without parental consent.
These circumstances usually include treatment for substance abuse problems, psychiatric
disorders, or sexual transmitted diseases.
(Option 2) This client has signs/symptoms of systemic infection and possible dehydration or
sepsis, an emergent condition. It is unknown when the parents or guardians can be reached. It
would be negligent to not further assess and treat a potentially worsening condition. It is
assumed that the parents or guardians would want safe, quality care for the client.
(Option 3) Qualifications for the status of emancipated minor are subject to state legislation but
usually include individuals age <18 who are parents or pregnant, married, living as financially
independent, or in the military. This client needs care that should be rendered regardless of
status.
(Option 4) Providing follow-up advice will not stabilize a potentially serious medical
condition. Care must be provided.
An underage client whose parents or guardians cannot be contacted and who needs emergency
care should receive all necessary medical care until a parent or guardian can be reached to
provide consent.
Following a motor vehicle crash, the nurse stops to help a victim who has a laceration with
spurting blood. The nurse giving reasonable assistance could be held liable despite Good
Samaritan laws in which situations? Select all that apply.
Good Samaritan laws prevent civil action against nurses who stop of their own accord (eg, not
part of their job duties) to help injured individuals after an accident. The nurse cannot receive
payment for any care given (Option 1).
It is essential for the nurse to perform in the same manner as any reasonable and
prudent medical professional would in the same or similar circumstances. A reasonable,
prudent nurse would apply pressure to help control an arterial bleed (Option 3).
(Option 2) Although this nurse is not legally obligated to offer assistance, it can be argued that
there is an ethical responsibility. Once the nurse starts to render care, the nurse is responsible to
continue until the care can be handed off to an appropriate caregiver, such as a paramedic. The
nurse is not obligated to accompany the client to the hospital.
(Option 4) Knowing the client does not affect the application of Good Samaritan laws.
(Option 5) This nurse is not liable for the victim's outcome as long as the nurse performs in a
competent manner.
Good Samaritan laws prevent civil action if a nurse stops to assist after an accident, as long as
the nurse acts competently, continues care until another appropriate caregiver takes over, and
does not accept money.
A client with metastatic esophageal cancer says, "I don't want to be kept alive being fed by a
tube." What are the most appropriate ways for the nurse to ensure that this information is
available to all who may need it for future decision-making? Select all that apply.
Advance care planning is a process that includes:

 Considering treatments that may be needed in the future
 Making decisions to guide future treatments, particularly if the client is no longer able to
make own decisions
 Ensuring that treatment decisions are legally documented on the appropriate forms, such
as the advance directive, and in the medical record (Option 1)
 Ensuring that advance directive documents are in the medical record so that they are
available to HCPs who care for the client in the future (Option 3)
 Ensuring that the health care proxy (or durable power of attorney for health care)
has information and documentation to support that role if this person needs to make
decisions for the client (Option 2)
The nurse's role as advocate includes discussing options with the client and ensuring that the
client's wishes are communicated and documented appropriately so that the health care proxy
and health care team will have the necessary information.
(Option 4) An informed consent is necessary for the client or surrogate decision maker to
approve certain treatments, procedures, and surgeries. The nurse's role in obtaining informed
consent is to obtain and witness a signature once the HCP has explained the procedure, its risks
and benefits, and answered any questions. This client is not providing consent for any procedure
at this time.
(Option 5) A DNR order is used to prevent resuscitation in someone with a life-limiting illness.
A DNR order does not provide direction for nutrition supplementation.
An advance directive is used to communicate a client's wishes when the client is not able to
communicate them him/herself. The nurse can advocate for the client by ensuring that expressed
wishes are communicated in the advance directive and medical record and by encouraging the
client to share this information with the appointed health care proxy.
The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff.
A health care provider approaches the nurse and asks, "How is my client Mrs. Jones in Room
312 doing?" Which response by the nurse is appropriate?
The nurse is ethically and legally obligated to protect clients' privacy and

maintain confidentiality of their medical information. If another staff member asks a question
about a client's medical information in an open area with visitors, the nurse should first move
the conversation to a secure area. Answering the question will promote further conversation,
making it likely that the client's privileged health care information will be discussed and
overheard by others. The best response is to suggest changing the location of the conversation so
that the information can be discussed privately (Option 2).
(Option 1) This response is neither accurate nor helpful because the nurse knows how the client
was earlier in the day. It is best to make the conversation private so that the nurse can respond to
the question appropriately.
(Option 3) Although vague, this response in a public area (ie, cafeteria) violates the client's
privacy by acknowledging the client's presence in the hospital, where the response may be
overheard by others. In addition, it does not provide accurate information.
(Option 4) It is appropriate to direct questions about the client to the currently assigned nurse;
however, this response violates the client's privacy by confirming the client's presence in the
hospital. It is best to make the conversation private before sharing any information.
The nurse must protect clients' privacy and ensure that their medical information remains
confidential. Conversations about the client with other staff, even those regarding the client's
presence in the hospital, should occur in a private area.
The nurse prepares to teach an in-service on legal issues related to nursing. Which legal terms
are followed by an appropriate example? Select all that apply.
Assault is an act that threatens the client and causes the client to fear harm, but without the
client being touched (Option 1).
False imprisonment is the confinement of a client against the client's will or without legal
justification (eg, client is not a threat to self or others) (Option 3).
Invasion of privacy includes disclosing medical information to others without client consent.
Under the Health Insurance Portability and Accountability Act (HIPAA), a client's information
regarding medical treatment is private and cannot be released without the client's
permission (Option 5).
(Option 2) Battery involves making physical contact with the client without permission.
This includes harmful acts or acts that the client refuses (eg, performing a procedure). When
interacting with the client, it is important to practice veracity, the ethical principle of being
truthful.
(Option 4) An emancipated minor is an individual under the age of legal responsibility who has
been legally freed from parental control through a court order (eg, due to enlistment in the
military, marriage, pregnancy). The parent in this situation would not need to be called. Clients
have the right to be informed of risks and benefits of procedures prior to care and to give
informed consent.
Clients have the right to privacy and to give informed consent prior to medical care. Assault is
an act that threatens the client, causing the client to fear harm without the client being touched.
Battery is physical contact against a client's will or without legal justification. False
imprisonment includes restraining a competent client without the client's permission.
The acute care clinic nurse administers a prescribed narcotic for a client with renal colic and then
discharges the client without ensuring that the client has a designated driver. The client is
subsequently involved in a motor vehicle accident causing injury to self and others. Which
ethical principle did the nurse violate?
The nurse violated the ethical principle "nonmaleficence" (ie, do no harm). It is rare to see a
nurse inflict intentional harm. However, problems do occur due to unintentional harm, which is
usually a result of poor clinical judgment.
Beneficence is a nurse's duty to promote good and do what is best for the client.
(Option 1) Autonomy is allowing the clients to choose the direction of their care. This is
accomplished with advanced directives along with informed consent and choices regarding
proposed treatments.
(Option 3) Paternalism is a type of beneficence whereby clients are treated as children. The
nurse claims to know what is best for the client and coerces the client to act as the nurse wishes
without considering the client's autonomy.
(Option 4) Veracity refers to the duty to tell the truth. This principle should always be applied
to client care and documentation.
Nonmaleficence is the ethical principle of doing no harm. All nurses must exercise sound
clinical judgment to prevent harm, even if it is unintentional, to their clients.
An elderly client visits the clinic for an annual examination, which includes updating the client's
advance care plan. When assessing the client's advance care planning needs, which topics should
the nurse discuss? Select all that apply.
Advance care planning is an ongoing process that should be revisited yearly and after changes in
condition. Legal documentation is needed to ensure that the client's advance care plan is carried
out correctly.
Advance care planning documents may include the following:
 A health care proxy (durable power of attorney for health care or medical power of
attorney) is a person appointed by the client to make decisions on behalf of the client.
The proxy document only goes into effect when the health care team determines that the
client lacks the capacity to make decisions. This should be deactivated if the client
regains decision-making capacity.
 A living will is an advanced directive describing the type of life-sustaining treatments
(eg, cardiopulmonary resuscitation, intubation, mechanical ventilation, feeding tube) that
the client wants initiated if unable to make decisions.
(Option 1) The financial power of attorney form can help clients having difficulty managing
financial affairs and needing someone to help; however, it is not part of the advance care
planning process.
(Option 3) The client must choose a beneficiary for life insurance policies; however, life
insurance is not part of the advance care plan.
(Option 5) A safe deposit box can be a good place to ensure that legal documents are stored
safely. It is not part of the advance care planning process.
Advance care planning allows the client to determine desired treatments (eg, cardiopulmonary
resuscitation, intubation, mechanical ventilation) and decision makers in the event the client is
unable to do so. Advanced directives are legal documents outlining these wishes and include
living wills and health care proxies (durable powers of attorney for health care or medical power
or attorney).
The hospital nurse coming on duty notifies the unit of a delay due to a motor vehicle accident.
The off-going nurse has an important appointment and must leave on time. How should the off-
going nurse handle the situation?
The off-going nurse must ensure that there is another registered nurse responsible for the care of
the clients, if this is not done then abandonment has occurred. A deliberate report must be given
using standardized format for continuity of care. During the hand-off, objective data should be
provided about the clients' current status and response to treatment to enable planning care.
The off-going nurse should let the charge nurse know as this individual is responsible for the
staffing of the unit and would have the authority to try different options, such as asking another
nurse on the unit to stay or notifying the main nursing office to obtain a nurse from another unit.
In addition, there is no established time frame for the incoming nurse's actual arrival; a
significant amount of time could pass before this inadequate staffing issue is resolved.
(Option 1) This general vague oversight is an inadequate report and transfer of responsibility to
the other nurse.
(Option 2) Tape recording a report is a legitimate method of communication as long as there is
an opportunity to ask questions. However, this does not resolve the issue of procuring a nurse to
take over responsibility for the clients' care.
(Option 4) Although this would help transmit essential information, it does not accomplish
procurement of another nurse to be responsible for the clients' current care.
In a facility with 24-hour care, prior to leaving, an off-going nurse must have another nurse take
over the responsibility for the clients' care and give an appropriate report for these clients.
Leaving clients without these elements can be deemed to be an act of abandonment.
The charge nurse is reviewing events that staff nurses experienced during the shift. Which
events require an incident/occurrence report to be completed? Select all that apply.
Incident/occurrence reports are used in a health facility to document events that pose

unanticipated actual or potential risk to the health or safety of a client, visitor, or employee.
Incident/occurrence reporting is a method of quality improvement and should not be considered
punitive in nature or be documented in the health record. Examples of events requiring reporting
include:
Assault and injury
 Physical, verbal, or sexual assault occurring in a health facility (Option 2)
 Client falls, with or without injury
 Staff and visitor falls, regardless of acceptance or refusal of treatment (Option 5)
Treatment and intervention
 Failure to obtain or intervene upon the results of diagnostic procedures (Option 3)
 Inadequate or delayed diagnosis and monitoring
 Delay, omission, or incorrect performance or administration of prescribed therapies and
medications
 Hospital equipment failure
(Option 1) Withdrawal of life support in clients deemed brain dead is an expected and clinically
justified course of care, and should be documented in the health record.
(Option 4) Incident/occurrence reports are used to document clinical health and safety issues;
managerial issues (eg, tardy or absent staff) should be documented in the employee's record.
Incident/occurrence reports are used to document events that pose actual or potential risk to the
health or safety of clients, visitors, or employees. Examples of reportable events include assault
and injury; delay, omission, or incorrect provision of treatment; and equipment failure.
Which emergency department client would be allowed to leave against medical advice after the
risks are discussed with the primary health care provider?
To leave against medical advice (AMA), a client must have the risks explained and be able to
understand them (ie, competent). Issues that can make a client ineligible to leave
AMA include danger to self or others, lack of consciousness, altered consciousness, mental
illness, being under chemical influence, or a court decision.
Despite it not being in the client's best health interest, the client with gastrointestinal bleeding
can leave AMA (Option 4).
(Option 1) Parents may not refuse life-, limb-, or organ-saving treatment on behalf of their
minor child for religious or personal reasons; they can make that decision only for themselves. If
the parents deny critical treatments to the child, the hospital may seek protective custody.
(Option 2) Suicidal ideation (ie, danger to self) is a criterion that prevents a client from being
allowed to leave AMA.
(Option 3) The client is not oriented x3 and is therefore not competent. There are 3 orientation
categories (time, place, and person); orientation to time is lost first. To be oriented, the client
must answer all questions in each category correctly.
After an explanation of the risks is given, a client must be considered competent in order to leave
against medical advice. A client with suicidal ideation or altered consciousness is not
competent. Parents may not refuse limb-, life-, or organ-saving treatment for a minor child based
on their own personal beliefs.
A housekeeping employee tells the staff nurse of having a headache and asks for
acetaminophen. How should the nurse respond?
Although acetaminophen is an over-the-counter drug, the nurse should not give it without a
prescription. By doing so, the nurse would be functioning outside the job description. There has
not been a proper assessment (eg, allergies, liver disease), and a legal caregiving relationship will
be established by administering the medication. If the employee does not want to go to the
employee health provider, the nurse can suggest that the employee purchase acetaminophen in
the gift shop.
(Option 1) It is advisable for the nurse to ask about liver issues prior to administering
acetaminophen, but this nurse has no prescription to administer it. Taking the medication from a
personal supply, rather than hospital stock, does not change the fact that the nurse is functioning
outside the job description while on duty.
(Option 2) The nurse could technically perform the assessment, but it is not within the nurse's
current role and job description. The employee health provider (or the emergency department)
should be used for this assessment.
(Option 3) The nurse should check for allergies before administering a drug, but this nurse has
no prescription to administer acetaminophen. Acetaminophen being an over-the-counter
medication does not change this fact.
The nurse should not give medication to an employee without a prescription even if it is an over-
the-counter drug.
Which are correct understandings of applying nursing ethical principles? Select all that apply.
Ethical principles guide the nurse in making appropriate decisions and acting accordingly. They
speak to the essence but not to the specifics of the law. Fidelity is exhibiting loyalty and
fulfilling commitments made to oneself and others. It includes meeting the expected
responsibilities of professional nursing practice and provides the basis of accountability (taking
responsibility for one's actions) (Option 3).
Nonmaleficence means to do no harm and relates to protecting clients from danger when they
are unable to do so themselves due to a mental/physical condition (eg, children, client with
Alzheimer disease) and from a nurse who is impaired (Option 5).
(Option 1) Autonomy is the right to make decisions for oneself (eg, informed consent).
Although having an advance directive is an example of autonomy, requiring one violates this
principle. The client has a right to refuse even if the nurse believes it is in the client's best
interest.
(Option 2) When a diagnosis is withheld, even if due to the nurse's or family's good intentions,
it violates the principle of autonomy. Beneficence means to do good (eg, implementing
interventions to promote the client's well-being).
(Option 4) The principle of justice refers to treating all clients fairly (ie, without
bias). Veracity is telling the truth as a fundamental part of building a trusting relationship.
Nonmaleficence is doing no harm, fidelity is loyalty and commitment, justice is equal treatment
for all, beneficence is doing good for the client's best interest, and autonomy is making decisions
for oneself.
The home health nurse is providing long-term care to several clients. Which are examples
of inappropriately crossing professional boundaries? Select all that apply.
Professional boundaries set limits to maintain a therapeutic professional relationship between

the nurse and client. However, the line between professional and personal interactions is
sometimes blurred in extended relationships or when care is given in the client's home. The
nurse should always put the client's needs first and never seek personal gain (eg, accepting gift
worth >$20, asking for financial investment/loan) (Options 1 & 5).
The nurse should follow a facility's policy on professional standards of behavior. In the absence
of a formal policy, the nurse should consider if the action would be appropriate to include in the
medical record. If the nurse is unsure, it may be indicative of a violation of professional
boundaries (eg, flirting with client, consuming alcoholic beverages with client) (Option 6).
(Option 2) An occasional visit to a previous client in a different circumstance (hospital, nursing
home) is considered appropriate and caring.
(Option 3) It is appropriate for the nurse to offer assistance in meeting a client's spiritual needs
if the client desires it. The nurse should not force their own beliefs, religion, or practices on the
client.
(Option 4) Sending a sympathy card to acknowledge a family's loss is a holistic and therapeutic
measure.
Professional boundaries involve maintaining a relationship that benefits the client, not the nurse,
and to which the nurse would not be reluctant to admit. It is generally not appropriate to
socialize with a current client after hours, ask for a financial investment/loan, or accept a
valuable gift.
Which of the following are violations of protected client health information? Select all that
apply.
Under the Health Insurance Portability and Accountability Act (HIPAA) and the Personal
Information Protection and Electronic Documents Act (PIPEDA), a client's information
regarding medical treatment is private and cannot be released without the client's permission.
There must be a reasonable effort to limit the use of, disclosure of, and requests for protected
health information (PHI) to the minimum necessary to accomplish the intended purpose.
The client's PHI should not be shared with a partner or spouse without the client's
PHI is shared with an employee on a "need-to-know" basis. A transporting employee does not
need to know the client's diagnosis, only information related to positioning/transferring or
personal protective equipment (for infection precautions), if applicable (Option 4).
(Option 1) A client overhearing report through a privacy curtain is inadvertent communication
and is not considered a violation.
(Option 2) Calling a client by the first and last names in the waiting room is not a violation as
long as no other pertinent information is given.
(Option 5) Any employee can provide socially acceptable well wishes to a client. This does not
involve PHI.
The Health Insurance Portability and Accountability Act and the Personal Information Protection
and Electronic Documents Act requirements related to protected health information include not
giving results to a spouse without permission or telling a client diagnosis to an employee who
does not need to know it. It is not a violation to call clients by their names, have information
overheard inadvertently, or indicate well wishes.
A client with terminal cancer arrives in the emergency department unresponsive and in
respiratory distress. The client's sister is the legal medical power of attorney. Both the client's
spouse and sister are present. Which action by the nurse is appropriate at this time?
Advance directives are legal documents that allow clients to make decisions about their future
medical treatment in case the client later becomes medically incompetent (eg, end of life,
dementia, brain injury). The most common forms are living will and medical power of
attorney (POA) (ie, health care surrogate/proxy). A living will declares the client's wishes
related to specific situations (eg, do not intubate). A medical POA allows the client to designate
a specific decision-making individual who can advocate for the client as needed and can be
flexible in changing circumstances (Option 2).
(Option 1) A client's spouse is typically the primary decision maker. However, clients have the
right to declare any specific individual who they trust as their agent with medical POA, and the
agent becomes the final decision maker.
(Option 3) The client should receive treatment immediately if there are no advance directives or
family members present, but in this case, the agent authorized with medical POA is present and
should approve the treatment plan before interventions are initiated.
(Option 4) If the client's medical POA agent is present, treatment should not be delayed by
requesting a living will as the agent will advocate for the client's wishes and has final decision-
making authority.
Medical power of attorney (POA) is an advance directive that allows clients to designate a
specific decision-making individual who advocates on their behalf if they become medically
incompetent. Clients have the right to declare any individual they trust as their agent with
medical POA, and that individual becomes the final decision maker.
Which situations would prompt the health care team to use the client's advance directive to make
a decision regarding care? Select all that apply.
Advance directives give people the chance to make decisions about their medical treatment
ahead of time in case they are unable to personally make their wishes known. The 2 most
common forms are living wills and durable power of attorney for health care (health care
surrogate/proxy).
A client who is alert and oriented can directly address a health care decision. Clients in a coma
(GCS score ≤7) or with expressive aphasia would need an advance directive to make treatment
decisions because they cannot directly express their wishes. Aphasia involves the inability to
express thoughts and comprehend language due to brain dysfunction and includes both
verbalizing and writing (Options 2 and 4).
(Option 1) Mental capacity is not affected in spinal cord compression. The client is able to
speak.
(Option 3) An adult who is mentally capable of making decisions has the right to refuse
treatment for any reason at any time whether the health care provider believes it is in the client's
best interest or not.
(Option 5) A client who is oriented can make and communicate decisions for him/herself
although unable to verbalize. The client could nod or write out wishes.
Advance directives take effect when the client is unable to speak for him/herself due to such
conditions as mental incapacity. Aphasia involves the inability to express thoughts and
comprehend language due to brain dysfunction and includes both verbalizing and writing.
A newly reassigned nurse enters a hospital room at the beginning of the shift and finds the client
unconscious and unresponsive. Resuscitation is initiated and then continued by the rapid
response team. The nurse realizes that there is a do not resuscitate (DNR) prescription posted in
the client's chart. Which action is correct?
Many health care professionals react to an emergency situation automatically. However, some
states and provinces will further penalize health care workers with loss of their professional
license if they fail to render cardiopulmonary resuscitation in an emergency situation.
Health care professionals will not be penalized for an honest mistake. However, resuscitation
must end immediately after they are notified of the error (Option 1).
(Option 2) Continuing treatment until the code status is verified with the health care provider
(HCP) constitutes malpractice. Before a do not resuscitate prescription can be posted in a client's
medical record/chart, the HCP must provide documentation that the client's code status has been
established through consultation with the client or family.
(Options 3 and 4) Gross negligence of a client's advance directive can result in legal action.
Failure to stop an erroneous code on a client with an advance directive in a timely fashion may
result in legal action.
The nurse is caring for a client newly diagnosed with mild Alzheimer disease. Which action
should the nurse prioritize at this time when teaching the client and family?
Stages of Alzheimer disease
 Immediate recall affected, distant memories preserved

 Gets lost easily
Stage I:
 Trouble remembering words & common objects
Mild
 Difficulty finding words, repetitive
 Cognitive impairment with progressive decline
Stage II:  Reduced ability to perform ADLs

Moderate
 Behavioral changes (eg, argues easily, anxious, depressed)
 Paces & wanders
 Needs close supervision
 Decreased mobility
Stage III:  Dependent on others for ADLs
Severe  No recognition of self or previously familiar people
 Fragmented memory
ADLs = activities of daily living.
Alzheimer disease (AD) is a progressive neurocognitive disorder resulting in memory loss,

personality changes, and inability to perform self-care. Due to the progressive course of AD, it
is important to discuss advance directives (eg, living will, medical power of attorney) while the
client can make informed decisions (Option 2).
(Option 1) Disruptive behaviors (eg, agitation, aggression) are common as the disease
progresses to moderate or late stages and can be very unsettling. However, caregivers can learn
behavioral management techniques at any stage of AD.
(Option 3) Remaining mentally active (eg, doing crossword puzzles) may assist in slowing
disease progression. However, it is more important to put an advance directive in place in the
early stages of the disease.
(Option 4) Assistive services (eg, assisted living, adult day care, respite care, meal assistance)
are very helpful, especially for clients with moderate to severe dementia. However, caregivers
can make decisions regarding assistive services at any disease stage.
Clients with Alzheimer disease should be encouraged to make advance directives in the early
stages of the disease, while they can make informed decisions.
The nurse caring for a terminally ill client asks if the client has an advance directive. The client
states, "I already have a power of attorney." What is the best response by the nurse?
A power of attorney (POA) designates a representative to act on a person's behalf in the event
that the individual becomes incapacitated. There are different types of POAs, including medical
and financial.
An advance directive or living will describes the client's health care decisions (eg, do not
resuscitate). As part of an advance directive, the client may designate a representative to make
health care decisions for the client - a durable POA for health care or POA for health care
(Canada). This client's statement requires further clarification regarding what type of POA is in
place (Option 4).
(Option 1) The nurse should not assume that the client's affairs are in order based on this
statement. Further clarification is needed to determine whether the client has made the
appropriate arrangements regarding health care decisions.
(Option 2) Although it is correct that the POA makes decisions for a client only when the client
is no longer able to make them, the nurse first needs to determine what type of POA is in place.
(Option 3) Lawyers can help with end-of-life paperwork, but the priority is to clarify whether
the client has the appropriate POA in place.
An advance directive makes clear a client's health care wishes (eg, do not resuscitate). A power
of attorney (POA) designates a representative to act on a person's behalf. It is important to
clarify that the client has the type of POA who can make health care decisions (durable POA for
health care, POA for health care [Canada]).
A nurse is documenting notes in the client's electronic record after making rounds on assigned
clients. Which entry is an appropriate documentation?
The electronic record is a legal document and should contain factual, descriptive,
objective information that the nurse sees, feels, hears, and smells. It should be the result of
direct observation and measurement. "Inspiratory wheezes heard in bilateral lung fields" best
fits these criteria. The nurse should avoid vague terms such as "appears," "seems," and
"normal." These words suggest that the nurse is stating an opinion and do not accurately
communicate facts or provide information on behaviors exhibited by the client. The nurse
should provide exact measurements, establish accuracy, and not provide opinions or
assumptions.
(Option 1) The nurse should not use the word "appears" as it is too vague. "Eyes closed" is a
factual observation. A more accurate entry would be, "Client lying in bed with eyes closed.
Respirations even and unlabored."
(Option 2) It is a good practice to document client quotes. However, in this case, the nurse
should have elicited more information from the client, such as a pain scale, and then documented
the analgesic the client was given.
(Option 4) This documentation would be more descriptive if it listed how much urine, its color
and clarity, and if an odor was present.
Nursing documentation should be factual, descriptive, and contain objective information that the
nurse sees, hears, feels, or smells. It must include direct observation and measurement.
The nurse is caring for a hospitalized client. Which are the best examples of narrative
documentation to provide legal malpractice protection for the nurse after an adverse
event? Select all that apply.
Documentation should be clear, concise, and accurate to be credible, which includes being
timely, truthful, and appropriate. When charting a symptom or situation, the nurse should chart
the interventions taken and the client response.
An adverse event is an unusual occurrence, accident, or injury unrelated to the client's underlying
condition. Adverse events must be acknowledged and documented in the chart. It is essential
for the nurse to note the actions taken in response to the event (eg, client teaching, safety
precautions) and the time frame in which they were performed. Documenting the key,
pertinent negatives indicating that no client harm resulted and the appropriate interventions
implemented to rectify or reduce harm will minimize nursing liability. If an incident report is
also required, it is separate from the medical record and should never be mentioned in the client's
chart.
(Option 1) Lack of a verbalized symptom does not ensure that no injury was sustained. In
addition, documentation should be objective and not contain opinions.
(Option 2) A generic notation of "continue to monitor" is meaningless; the nurse should
monitor all clients regardless of the situation.
(Option 5) "Suspicious" is subjective wording; the nurse should document exactly which
actions appeared suspicious (eg, rapidly hides package every time nurse enters room; will not let
nurse see package).
After an adverse event, the nurse should document objective, specific assessments and
interventions. These include signs/symptoms indicating a lack of client harm and any corrective
actions taken.
The nurse is working with a client admitted with delirium and reduced level of consciousness
due to pneumonia and respiratory failure. The nurse anticipates that the client may need to be
intubated soon. The client is not able to make decisions. Who will make decisions for the
client?
When a client is unable to make decisions, the health care proxy is legally able to make decisions
for the client. In the event that the health care proxy is unable to fulfill this role, the
responsibility goes to the alternate proxies identified on the advance directive. If the client does
not have a health care proxy, the family members would make decisions for the client.
Occasionally, there is no family and no proxy. If this happens, a proxy may be appointed, an
ethics board may make the decision, or the HCP may be responsible for making the decision.
(Options 1, 2, and 3) The health care proxy would be the legally appointed primary decision
maker.
The role of the health care proxy is to make decisions for a client who is unable to do so.
Ideally, the proxy will have a good understanding of the client's wishes and will be emotionally
capable of fulfilling this important role.
Which actions by a registered nurse are reportable to the state board of nursing? Select all that
apply.
The National Council of State Boards of Nursing advises any individual who has knowledge of a
potential violation of a nursing law or rule to file a complaint with the appropriate state board of
nursing. A nurse should be knowledgeable concerning the presiding board's stance on
mandatory reporting and which actions are considered reportable. In general, reportable actions
may include any behavior by a licensed nurse that
is unsafe, unethical, incompetent, impaired (eg, by substances or a mental or physical
condition), or in violation of nursing law.
 Practicing outside of the scope of the license is reportable even if the practice meets
quality standards (Option 1).
 Documenting an intervention that was not performed is considered falsification of
records regarding client care and is a reportable action (Option 3).
 Stealing narcotics is a criminal offense (a violation punishable by the state that can
result in prison or a fine) and is reportable in all states. Many states offer an alternate
rehabilitation program to nurses who diverted or abused drugs (Option 4).
 Abandonment (eg, leaving without proper replacement of personnel and transfer of
responsibility for client care) is reportable in all states (Option 5).
(Option 2) Work habits are handled under the facility's management policies and are often part
of the criteria for discipline and/or termination. If the facility has 24-hour care, the off-going
nurse cannot leave without someone assuming responsibility for the clients or waiting for the
tardy nurse.
Nurse offenses reportable to the state board of nursing include criminal acts (such as theft),
practicing outside of the scope, falsification of records, and client abandonment. Any individual
may file a complaint regarding an action that is potentially unethical, incompetent, impaired, or
in violation of nursing law.
The emergency department nurse is obligated to make a report for which situations? Select all
that apply.
There are several circumstances in which the nurse is legally required to report to appropriate
civil authorities:
 Suspected elder abuse must be reported to the appropriate authorities for investigation.
The nurse has a legal obligation to report signs of abuse regardless of clients' ability or
willingness to advocate for themselves (Option 2).
 The nurse should report deaths that meet medical examiner reporting guidelines (eg,
suspected to be the result of a crime, trauma, or suicide) to the authorities for
investigation. The local medical examiner has the legal authority and obligation to
perform an autopsy independent of the family's wishes (Option 3).
 For the sake of client safety, nurses should immediately report impaired or intoxicated
health care workers, regardless of their position (Option 5).
 Under the Health Insurance Portability and Accountability Act, a client's reason for an
emergency department visit cannot be communicated to employers without the client's
 Health authorities must be notified of a reportable sexually transmitted disease regardless
of client wishes. Depending on the condition, authorities may report findings to sexual
contacts, but it is a violation of client privacy for the nurse to share this information with
the client's family or spouse (Option 4).
The nurse is required to report an impaired coworker, a suspicious death, and elder abuse to
appropriate authorities. The nurse is legally prohibited from sharing health information with
employers or family members without the client's permission.

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